Treatment of Heavy Menstrual Bleeding with Quarter-Size Clots
Start with combined oral contraceptives containing 30-35 μg ethinyl estradiol (with levonorgestrel or norgestimate) as first-line therapy after ruling out pregnancy, infection, and structural lesions. 1
Initial Evaluation
Before initiating treatment, you must exclude:
- Pregnancy (urine or serum hCG) 1
- Sexually transmitted infections (particularly in reproductive-aged women) 1
- Structural pathology (fibroids, polyps) via pelvic ultrasound if indicated 1
- Anemia (CBC with hemoglobin/ferritin) 2
Key clinical predictors of significant blood loss include quarter-size clots (≥1 inch diameter), low ferritin, and "flooding" (changing pad/tampon more frequently than hourly). 2 Your patient's quarter-size clots meet this threshold and warrant aggressive treatment.
First-Line Medical Treatment Algorithm
Step 1: Combined Oral Contraceptives
Initiate monophasic combined oral contraceptives with 30-35 μg ethinyl estradiol plus levonorgestrel or norgestimate. 1 This reduces menstrual blood loss by inducing regular shedding of a thinner endometrium and decreases cramping. 1 Additional benefits include acne improvement and reduced risk of endometrial and ovarian cancers. 1
Critical safety consideration: Assess thrombotic risk factors before prescribing, as combined oral contraceptives increase venous thromboembolism risk three to fourfold. 1 Monitor blood pressure at follow-up visits. 1
Step 2: Add NSAIDs if Bleeding Persists
If bleeding continues despite oral contraceptives, add NSAIDs (mefenamic acid, indomethacin, or diclofenac) for 5-7 days during bleeding episodes. 1, 3 NSAIDs reduce menstrual blood loss by 20-60% and work regardless of whether bleeding is anovulatory or ovulatory. 3
Do not use aspirin—it may paradoxically increase bleeding in some women. 3
Step 3: Consider Tranexamic Acid
If hormonal therapy is contraindicated or immediate pregnancy is desired, tranexamic acid reduces menstrual blood loss by 40-60%. 1, 3 However, it is contraindicated in women with active thromboembolic disease or history/risk of thrombosis. 1, 3
Management of Persistent Bleeding
Reassure the patient that unscheduled bleeding is common during the first 3-6 months of hormonal therapy and generally not harmful. 1, 3 However, if bleeding persists beyond this initial period, re-evaluate for:
- IUD displacement (if applicable)
- New uterine pathology (polyps, fibroids)
- Pregnancy
- Infection 1
If bleeding persists despite treatment and the patient finds it unacceptable, counsel on alternative contraceptive methods including the levonorgestrel-releasing intrauterine system (LNG-IUS), which reduces menstrual blood loss by 71-95%. 3
Alternative Options for Specific Scenarios
If Hormonal Therapy Fails or Is Contraindicated
- Levonorgestrel-releasing intrauterine system (LNG-IUS): Most effective non-surgical option, reducing blood loss by 71-95% 3
- Tranexamic acid: 40-60% reduction in bleeding 3
- NSAIDs alone: 20-60% reduction 3
If Patient Has Underlying Bleeding Disorder
Heavy menstrual bleeding with flooding, prolonged menses, or accompanied by personal/family history of bleeding suggests an underlying bleeding disorder and requires hematology referral. 2 Approximately 90% of women with bleeding disorders experience heavy menstrual bleeding. 2
Follow-Up
No routine follow-up is required for patients on combined oral contraceptives, but patients should return for side effects or concerns. 1 At follow-up visits, assess satisfaction with the method and any health status changes. 1
Common Pitfalls to Avoid
- Do not use aspirin for menstrual bleeding control 3
- Do not prescribe combined oral contraceptives without assessing thrombotic risk factors 1
- Do not dismiss quarter-size clots as normal—they indicate significant blood loss requiring treatment 2
- Do not overlook iron deficiency evaluation, as heavy menstrual bleeding commonly causes anemia 2